Summary

Comprehensive update consolidating evidence since the 2012/2014 stable ischemic heart disease guidelines for outpatient management of chronic coronary disease (CCD). Emphasizes team-based, patient-centered care with shared decision-making, social determinants of health, and cost/value considerations. Key new directions: limited role for long-term beta blockers without MI/LVEF≤50%, expanded use of SGLT2 inhibitors and GLP-1 RAs (including some without diabetes), shorter DAPT durations when bleeding risk is high, low-dose colchicine as adjunct, and recommendation against routine periodic ischemic/anatomic testing in stable asymptomatic patients.

Key Recommendations

High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) is first-line for all CCD patients, targeting ≥50% LDL-C reduction; add ezetimibe then PCSK9 monoclonal antibody if LDL-C remains ≥70 mg/dL in very high-risk patients.
Long-term beta blockers are NOT recommended in CCD patients without MI in past year, LVEF ≤50%, or another primary indication (angina, HTN, arrhythmia).
Either a beta blocker or calcium channel blocker is acceptable first-line antianginal therapy.
SGLT2 inhibitors are recommended in CCD patients with type 2 diabetes, HFrEF, or HFpEF (with or without diabetes) to reduce MACE and HF events.
GLP-1 receptor agonists are recommended in CCD patients with type 2 diabetes to reduce MACE; may also aid weight management in obesity.
Aspirin 75-100 mg daily is recommended indefinitely for secondary prevention; clopidogrel 75 mg daily is a reasonable alternative.
After PCI in CCD, DAPT for 6 months is standard; shorter durations (1-3 months followed by P2Y12 monotherapy) are reasonable when bleeding risk is high and ischemic risk low-moderate.
In CCD with concomitant AF requiring anticoagulation post-PCI, use DOAC plus P2Y12 inhibitor (drop aspirin within 1-4 weeks); avoid triple therapy beyond 30 days.
Low-dose colchicine 0.5 mg daily may be considered to reduce MACE in select CCD patients on maximally tolerated GDMT.
Annual influenza vaccination, COVID-19 vaccination, and pneumococcal vaccination are recommended in patients with CCD.
Routine periodic anatomic or ischemic testing without change in clinical/functional status is NOT recommended in stable CCD patients.
Dietary supplements (fish oil, omega-3, vitamins, antioxidants, calcium) are NOT recommended for CV event reduction; only prescription icosapent ethyl is supported in select patients with elevated triglycerides on statin therapy.

Thresholds & Doses

LDL-C reduction goal: ≥50% with high-intensity statin; intensify if LDL-C ≥70 mg/dL
High-intensity statin doses: atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily
BP target: <130/80 mm Hg in CCD with hypertension; optimal DBP 70-80 mm Hg
Hemoglobin A1c goal: <7% generally; <8% or <8.5% in older adults (>65 y) with CCD/comorbidities
Aspirin dose: 75-100 mg daily (81 mg in US); no benefit of 325 mg over 81 mg (ADAPTABLE)
Ticagrelor secondary prevention dose: 60 mg twice daily (post-MI 1-3 years out, PEGASUS)
Low-dose rivaroxaban for stable ASCVD: 2.5 mg twice daily plus aspirin (COMPASS)
Colchicine dose: 0.5 mg daily; avoid if eGFR <30 mL/min/1.73 m²
Icosapent ethyl: 4 g/day for triglycerides 150-499 mg/dL on statin (REDUCE-IT)
Sodium intake: <2300 mg/day (optimal <1500 mg/day)
Saturated fat: <6% of total calories
Physical activity: 150-300 min/week moderate or 75-150 min/week vigorous aerobic activity, plus resistance training ≥2 days/week
BMI categories: overweight 25-29.9 kg/m², obesity ≥30 kg/m²; weight-loss drug therapy if BMI ≥30 or ≥27 with comorbidities
Bariatric surgery candidate: BMI ≥40 or ≥35 with weight-related comorbidity
Very high-risk ASCVD: multiple major ASCVD events OR 1 major event plus ≥2 high-risk conditions (age ≥65, FH, diabetes, HTN, CKD eGFR 15-59, smoking, LDL-C ≥100 on max statin/ezetimibe, HF)
Annual MACE risk categories: low <1%, intermediate 1-3%, high >3%
Cost-effectiveness thresholds: high value <$50,000/QALY; intermediate $50,000-<$150,000/QALY; low ≥$150,000/QALY
Recurrence rate after SCAD: up to 27% at 5 years
Avoid nitrates within 24h of sildenafil/vardenafil or 48h of tadalafil
Pneumococcal vaccination associated with 58% reduction in ACS events post-pneumonia hospitalization

Citations

Section 4.2.6 Lipid Management — high-intensity statin first-line; ezetimibe then PCSK9 mAb stepwise approach
Section 4.3.2 Beta Blockers — new recommendation against long-term beta blockers without MI/LVEF≤50%/other indication
Section 4.2.8 SGLT2 Inhibitors and GLP-1 Receptor Agonists — recommendations including in nondiabetic HF patients
Section 4.3.1 Antiplatelet Therapy and Oral Anticoagulants; Figure 9 — DAPT duration based on bleeding/ischemic risk
Section 4.3.4 Colchicine — 0.5 mg daily for secondary prevention (LoDoCo2, COLCOT)
Section 4.2.7 Blood Pressure Management; Table 12 — BP target <130/80 mm Hg
Section 7.1 Follow-Up Plan — no routine periodic testing in stable asymptomatic patients
Top 10 Take-Home Messages — summary of major guideline changes from 2012/2014 documents